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1 ISSN : Journal of the Korean Society of Radiology, Volume 7, Number 5 Additive Manufacturing of Patient-specific Femur Via 3D Printer Using Computed Tomography Images Wang Kyun Oh, Ki Seon Lim, Tea Soo Lee Chungbuk National University CT 영상을이용한 3D 프린팅으로환자맞춤형대퇴골첨삭가공 오왕균, 임기선, 이태수 충북대학교 Abstract Femur is the largest bone in the human body which supports the weight of body. A long pipeline shape of femur has little cancellous bone, so that regeneration is difficult when fracture happens. The fracture caused by an accident most frequently occurs at diaphysis. IM Nailing is the surgical method that implants an IM Nail into a medullary cavity for the fixation of fracture parts. However, a secondary fracture may happen if an IM Nail does not penetrate at the center of femur. In this study, a patient-specific femur was manufactured by a 3D printer using the computed tomography images scanned before surgery, which was used for the simulation of IM Nailing. It is expected that this result may prevent the secondary damage, reduce surgical operation time, and increase the precision. Key Words : Femur fracture, CT image, 3d printer, IM nail, Patient-specific, Additive Manufacturing 요약대퇴골은사람의뼈중가장길며체중을지탱하는골격체로대퇴골간은긴파이프모양이면서안에해면골이거의없어서골절이발생되면재생이어렵다. 사고로인하여발생되는대퇴골의골절은골간부가가장높은빈도로발생한다. 골절의수술방법은골수강에 IM Nail을삽입하여골절부위를고정하는 IM Nailing이다. 수술시대퇴골의중심으로진입하지못하면 2차골절등의피해가발생하기도한다. 본연구에서는수술전대퇴골의 CT IMAGE을이용하여 3D 프린터로환자맞춤형대퇴골을제작하여골수강으로 IM Nailing 시뮬레이션을할수있도록하였다. 수술중발생할수있는 2차적손상을방지하고시간단축, 정밀한수술을할수있을것이다. 중심단어 : 대퇴골골절, 컴퓨터단층영상, 3D 프린터, IM Nail, 맞춤형제작, 첨삭가공 Ⅰ. 서론 대퇴골 (Femur) 이란사람의뼈중가장크고긴 뼈로대퇴골몸통은앞쪽으로약간볼록하게나와있으며체중을지탱하는가장큰골격체이다. 정상한국인들의경우에는대게 40 cm에서 50 cm정도길이의단단한골조직이다. 대퇴골의양측말단부에는단단 Corresponding Author: Tea Soo Lee tslee@chungbuk.ac.kr Tel: Add. 52, Naesudong-ro, Heungdeok-gu, Cheongju-si, Chungcheongbuk-do, , South Korea Received : September 13, 2013 Revised :October 17, 2013 Accepted : October 25,

2 "Additive Manufacturing of Patient-specific Femur Via 3D Printer Using Computed Tomography Images" 한겉질뼈속으로성긴모양을가지는해면골도풍부히존재하지만가운데부분인몸통은긴파이프모양이면서안에해면골이거의없다. 따라서양측말단부에골절이생기면비교적수월하게뼈가다시붙을수있지만가운데몸통부위가골절되면상당수에서뼈가잘붙지않는다 [1]. 대퇴골간부골절은상당히강한외력이가해지기때문에분쇄골절이외에도주변연부조직의손상등이수반되는경우가많다. 대퇴골골절부위는중간부가가장높은빈도를보이는데다양한치료방법이개발되고있지만, 가장보편적이며, 좋은방법이라여겨지고있는것이골수강내금속정고정술이다. 협부골절시주된치료방법으로알려져있으며, 특히횡골절의경우가장이상적인방법으로알려져있다 [1]. 대퇴골간부골절중변형되어휘어진고령의골절환자와복합골절환자의대퇴골에 IM Nail(Intramedullary Nail) 을삽입하게되는데이때대퇴골의중심으로진입하지못하면 2차골절등의피해가발생하기도한다 [2]. 따라서수술전삼차원컴퓨터단층촬영영상으로환자대퇴부의휘어진정도나변형도, 골절상태확인후수술에사용할 IM Nail을선택하여수술계획을세운다. 그러나이방법은골수강내부의정확한중심부위를확인하기가어렵고외부에서보이는형태만을보고확인하는한계가있다. 본논문에서는방사선영상만을이용하여수술방법과도구를결정하지않고, 3D 프린터로수술환자대퇴부를실제크기로, 변형되고골절된상태를환자맞춤형형상으로제작하여수술전에직접손으로확인하고골수강내로금속정을정확한위치로삽입해볼수있도록대퇴골을제작, 수술시뮬레이션을통하여수술중발생할수있는오차를감소하여 2차골절의손상을방지하고, 수술시간을단축하여보다세밀하고정확한수술을할수있도록하고수술후합병증이나후유증등기타문제가발생할소지를줄일수있고수술계획을환자에게설명하는데큰도움이될수있도록하였다 [4][9][10]. Ⅱ. 재료및방법 1. CT 영상퇴행성질환으로무릎인공관절치환술을시행할환자의동의를구한후고관절에서무릎관절까지전체대퇴부를컴퓨터단층촬영하여 1mm 간격의영상을획득하였다 [Fig. 1]. 환자의 CT DICOM영상을 3D Workstation 삼차원영상재구성방법인 VR(Volume Rendering) 기법을이용하여관절부위를제거하고왼쪽과오른쪽대퇴골을각각분리하여삼차원입체영상으로변환하고, SSD(Shaded Surface Display) 기법으로영상을재구성하였다 [7][8] [Fig. 2]. Fig. 1. Femur CT Image Fig. 2. Femur MPR, VR Image 재구성된 SSD영상은 STL(STereoLithography) file로변환후 Export 하였다. 2. G-Code 파일변환제작에사용된 3D 프린터제원상의최대출력물크기는 mm 로길이가 40 cm 이상인 Femur 를한번에제작할수가없었다. STL파일을세부분으로분할하여모델을프린트하기위해 G-code 로변환해주는 Slicer Program 중에 Free Software CURA 12.12A[Fig. 3] 에서 3D 프린터에서모델출력을위해원료를쌓기위한경로와속도, 압출량, 제작물의밀도 360

3 ISSN : Journal of the Korean Society of Radiology, Volume 7, Number 5 등을계산하여하여 G-code를생성하여삼차원프린터에서출력하였다. Fig. 3. CURA G-code 3. 3D 프린터본연구의환자맞춤형대퇴골제작에사용한 3D 프린터는여러가지조형방식중에얇은층을쌓는재료가열경화성플라스틱을실처럼만든재료로, 플라스틱와이어 (Wire) 가노즐을통하여분출되어나오면서녹아한겹한겹쌓아올려형상을만드는 FDM방식을이용한와이어적층방식을이용하였다 [6]. 각각의부품을제작하여판매하는것을구입, 구조물을만들고구동모터와보드를조립하여제작하였다 [Fig. 4]. Fig. 5. 3D Printer 프린터를 PC에연결하여출력할때 PC에호스트프로그램인 Printrun[Fig. 6] 을설치하여프린터와직렬포트로연결하고수동으로노즐과히트베드의온도, X, Y, Z축의모터를제어하여프린터의구동을테스트할수있고 G-code를전송해서프린터가실제로출력을할수있도록하였다. 출력중에는총제작시간, 진행시간, 적층수와두께, 온도를확인할수있다. Fig. 4. 3D Printer component 재료의색상은뼈를잘표현하기위하여아이보리색상을사용하였고노즐의크기는 0.4mm, 적층밀도는 20%, 적층두께는 0.2mm 로설정하여출력되도록하였고프린터의노즐온도는재료의특성에맞는 230 도, 히트베드의온도는 100도로출력하였다. 히트베드의수평과영점을조절하였고베드와노즐의간격을조절하여배출되는재료가뒤틀림없이척층되도록하여구조물이출력되도록하였다 [3] (NP-MENDEL). Fig. 6. Printrun Program Ⅲ. 결과 1. 출력된대퇴골출력된대퇴골 3D Model이실제환자의원위대퇴부인무릎관절부위의퇴행성변화에의해변형된관절면이그대로표현되어출력되었고내측상과와외측상과, 슬개골면, 과간와, 근위부의소전자도대퇴부와 361

4 "Additive Manufacturing of Patient-specific Femur Via 3D Printer Using Computed Tomography Images" 같은크기와형태로만들어졌다. 중심부골수강의빈공간도실제와같은직경과형태를이루고있고대퇴골의두께도실제두께와같은크기인것을확인할수있었으며뼈의강도와같게하기위하여내부채움을 20% 로설정하여출력된것을확인할수있었다 [Fig. 7]. P=0.150 단위 cm 전체길이와대퇴골두, 대퇴경, 양측과간와, 내경의지름과외경의지름을측정하여대응표본 T-test를통하여통계적으로유의한차이를분석하였다 (Table 1). 제작된 3D Model과 CT Image가유의한차이가없었고같은크기로제작되었음을확인하였다. 전체출력된대퇴골은근위부의대퇴골두, 대퇴경, 대전자, 소전자, 전자간선과대퇴골간원위부무릎관절부위를포함하여실제길이와형태가일치하였다. 대퇴경부가대퇴골두와대퇴골간과이루는각도도정확하게표현되었다 [Fig. 9]. Fig. 7. 3D Printing Femur bone marrow cavity 정확도를측정하기위하여 DICOM Viewer에서 CT Image의길이와두께를측정하였고 Vernier calipers를사용하여 3D Model을측정하였다 [5] [Fig. 8]. Fig. 9. 3D Printing Femur Fig. 8. Direct Measurements Table 1. Accuracy Femur CT Model 3D Model % Difference length Middle Internal External Head Neck condyle IM Nailing 시뮬레이션대퇴골골절의치료방법인골수강내금속정고정술은대퇴골의골수강안으로 IM nail(intra medulla nail) 을삽입하게되는데이때대퇴골의중심으로진입하지못하면 2차골절등의피해가발생할수있어환자의대퇴골과같은골수강의크기와강도가같는환자맞춤형모형을가지고수술전미리골수강에 IM Nail 을삽입해보는시뮬레이션을하였다 [Fig. 10, 11]. 실제청주의 C 대학병원의정형외과수술실에서제작한모형을이용하여시뮬레이션을하여유용성검증을실시하였다. 362

5 ISSN : Journal of the Korean Society of Radiology, Volume 7, Number 5 을사용한다면병원에서도정형외과환자의수술전 3D Model을영상의학과에서제작하여제공할수있을것이다. 검사영상으로환자의뼈상태를진단하는방법이외의새로운진단방법이될것이다. 물론이방법이수술의성공과실패를좌우하는직접적인영향을줄수는없어도 CT 영상과같이활용하면정확한수술을할수있을것이다. 환자의대퇴골과똑같이변형되어휘어진정도, 골절된상태를 3D 프린터를이용하여환자맞춤형대퇴골을제작하여 IM Nailing 시뮬레이션을실시하였다. Fig. 10. IM Nailing Simulation Fig. 11. IM Nailing Simulation X-ray Image 연구결과수술전에직접손으로확인하고골수강내로금속정을정확한위치로삽입해볼수있도록대퇴골을제작, 수술시뮬레이션을통하여수술중발생할수있는오차를감소하여 2차골절의손상을방지하고, 수술시간을단축하여보다세밀하고정확한수술을할수있고수술후합병증이나후유증등기타문제가발생할소지를줄일수있고수술계획을환자에게설명하는데큰도움이될수있을것이라고정형외과수술의에게유용성검증을받았다. 향후대퇴골골절이외의인체다른부위의수술을필요로하는골절에도골절환자의손상된뼈를출력하여수술시절개부위와정도를결정하고수술방법과사용할도구를미리선택하여수술계획을세우는데도움이될수있도록연구를해야할것이며나아가서는인체의조직과장기도줄기세포와배양액을섞은바이오잉크를이용하여 3D 프린터로매우얇고작은세포를적층하여만든구조물로인공장기를생성할수있도록바이오 3D 프린터의연구도필요할것이다. Ⅳ. 결론본논문에서는고가의 3D Printer장비와전문인력을통하여주문제작되는인체 3D Model을 CT Image 를이용하여영상의학과에서 FDM제작방식을통하여저렴한비용으로제작할수있는방법에대하여연구하여환자맞춤형대퇴골을제작하였다. 현재제작크기가 40 cm 정도를제작할수있는장치는많지않다. 파일을분할출력하여접합하는방식 감사의글 이연구는 2012년한국연구재단의프로젝트 (No ) 를지원받아수행하였음. 참고문헌 [1] C. H. Chun, S. S. Kim, D. C. Kim, H. J. Yoo, The Treatment of Nonunion of Femoral Fractures with an Interlocking Nailing," Journal of the Korean Fracture Society, Vo1.8, No.3, pp , July,

6 "Additive Manufacturing of Patient-specific Femur Via 3D Printer Using Computed Tomography Images" [2] S. T. Jung, T. R.Yoon, J. K. Seon, Treatment of the Femoral Shaft Fractures with Interlocking Compression Nail," Journal of the Korean Fracture Society, Vol. 11, No. 2, pp , April, [3] [4] John Robert Honiballfdg The Application of 3D Printing in reconstructive surgery," Dissertation presented in fulfilment of the requirements for the degree MscIng in Industrial Engineering at the University of Stellenbosch, March [5] Gihyeon Kim, Ho-Joong Jung, Han-Jun Lee, Jae-Sung Lee, Seungbum Koo, Seung-Hwan Chang Accuracy and Reliability of Length Measurements on Three-Dimensional Computed Tomography Using Open-Source OsiriX Software Journal of Digital Imaging Volume 25, Number , [6] Carlos Henrique Pereira Mello, Rafael Calandrin Martins, Bruno Rosa Parra, Edson de Oliveira Pamplona, Eduardo Gomes Salgado, Rodrigo Tavares Seguso Systematic proposal to calculate price of prototypes manufactured through rapid prototyping an FDM 3D printer in a university lab Rapid Prototyping Journal Volume 16, Issue 6 pp , [7] Mark Frame and James S. Huntley Rapid Prototyping in Orthopaedic Surgery: A User 's Guide The ScientificWorld Journal Volume 2012, Article ID , 7 pages doi: /2012/838575, [8] R. Petzold, H. F. Zeilhofer, and W. A. Kalender, "Rapid prototyping technology in medicine basics and applications, " ComputerizedMedical Imaging and Graphics, vol. 23, no. 5, pp , [9] C. Hurson, A. Tansey, B. O 'Donnchadha, P. Nicholson, J. Rice, and J. McElwain, "Rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures, " Injury, vol. 38, no. 10, pp , [10] S. D. Gittard, R. J. Narayan, J. Lusk et al., "Rapid prototyping of scaphoid and lunate bones, " Biotechnology Journal, vol. 4, no. 1, pp , [11] J. Guarino, S. Tennyson, G. McCain, L. Bond, K. Shea, and H. King, "Rapid prototyping technology for surgeries of the pediatric spine and pelvis: benefits analysis, " Journal of Pediatric Orthopaedics, vol. 27, no. 8, pp , [12] V. Mironov, V. Kasyanov, C. Drake, and R. R. Markwald, "Organ printing: promises and challenges, " Regenerative Medicine, vol. 3, no. 1, pp ,

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